Zaine Pulliam, 17, center, rushes past family friend Jewels Hudson, 44, left, and his grandmother Madie Clark, 53, as he departs his family home in South Charleston, WV on Dec. 9, 2016. After Zaine and his two sisters lost their parents to heroin overdoses, Madie moved in to care for them. (Bonnie Jo Mount/The Washington Post)

To understand what the Trump administration faces as it tries to sharpen focus on the opioid epidemic, consider the “diseases of despair” that have hobbled the Appalachian region for the past two decades.

These three “diseases” – drug and alcohol overdose; suicide; and alcoholic liver disease – have long occurred at much higher rates inside Appalachia compared to outside of the region. But the disparity has become markedly pronounced; in 1999, the area's overall mortality rate was 12 percent higher than in other parts of the country. But by 2015, that difference had skyrocketed to 32 percent.

The disparities further intensify when you look just at deaths from overdose -- the biggest culprit of the three "diseases of despair." Those in the Appalachian region died from overdose 65 percent more commonly than those outside the region in 2015, according to the 2017 study "Appalachian Diseases of Despair" commissioned by the Appalachian Regional Commission.

Researchers at NORC University of Chicago's Walsh Center for Rural Health Analysis who carried out the study emphasized the regional nature of the opioid crisis, which, while affecting all corners of the United States, has especially hit the low-income area that stretches from northern Mississippi, Alabama and Georgia all the way up to the southern end of New York. Instead of studying states with the highest rates of opioid abuse, the researchers looked only at areas considered part of the Appalachian region. That includes just one whole state – West Virginia – and parts of a dozen other states.

There was a marked difference between portions of these states that fall within Appalachia and those that fall outside of it. In Appalachian Maryland and Appalachian Virginia, for example, mortality rates were 63 and 59 percent higher, respectively, than in the non-Appalachian portions of each state. I spoke with Michael Meit, one of the study’s co-authors, about this finding and the study's other interesting points.

Here are some of their conclusions:

1. The diseases of despair have a stronger foothold the closer you get to the center of the Appalachian region, with West Virginia at the epicenter.

In central Appalachia, they led to 94.4 deaths per 100,000 people – a rate 80 percent higher than in southern Appalachia, where there were 52.3 deaths per 100,000. In the zone in between, dubbed “south central, the rate was 65.1 deaths.

Meit said that to him, that was the most surprising part of the study and could reflect patterns in opioid prescribing, job economies where there's a high rate of injury and the location of pain clinics within the region.

2. Disease of despair are affecting Appalachians mainly in their prime working years.

For every age group, the mortality rate is greater among those who live within the region versus outside of it. But the difference is most pointed among people ages 25 to 34 – whose mortality rate is 55 percent higher – and for people ages 35 to 44, whose mortality rate is 59 percent higher.

“As we think about challenges that the Appalachian communities face in terms of rebuilding their economies, losing your workforce in the prime of their working years makes that a much more difficult challenge,” Meit told me.

There’s one bright spot here: Mortality rates remain significantly lower for Appalachians between ages 15 and 24, and only 15 percent higher than their counterparts outside the area. Meit said that statistic gives him some hope.

“As we think about how we solve this problem, part of it is treating the people already addicted, but the next part is preventing that next group,” Meit said.

Bottles of medications line the shelves at a pharmacy in Portsmouth, Ohio. (REUTERS/Bryan Woolston/File Photo)

3. There is great disparity among women dying of drug overdoses inside Appalachia versus outside of it.

Men overdose on opioids at much higher rates than women, and that’s true all over the country. But Appalachian women die from overdoses at higher rates compared to their counterparts outside the region. Men within the area are 75 percent more likely to die, while women are twice as likely to die. Meit told me he’s not exactly sure why that is.

One thing is becoming abundantly clear as America's opioid crisis receives more political attention: the problem is complex, with no one simple solution. In his speech last week, Trump outlined several steps his administration will take to start tackling the problem, including allowing states to temporarily shift the use of federal grant funds to target those with addictions and, in isolated areas like Appalachia, giving patients greater access to opioid treatment through telemedicine.

The president also briefly mentioned expanding the ability of mental health facilities to accept Medicaid patients, which could be done through issuing more waivers from a long-standing federal prohibition called the “IMD exclusion” (I wrote about this in Friday’s Health 202).

Meit said he's worried the stats might look even worse once they're updated with data from the last two years. That's due to the recent emergence of fentanyl, a synthetic painkiller that's about 50 times stronger than heroin and is linked to the recent shocking rise in fatalities nationwide.

"As bad as this looks in this report, I think once we get the 2016 data and 2017 data it’s going to be much more worse than that," Meit said.

Advocates are pleased Trump and his administration are calling attention to the problem (although they'd prefer some new funding to throw at it, too). Attorney General Jeff Sessions called it a “winnable war” in an address on Friday to several dozen U.S. Customs and Border Protection officers at Kennedy Airport in New York City.

BREAKING: Paul Manafort, and his former business associate, Rick Gates, have been told to surrender to federal authorities, per the Post's Roz Helderman and Matt Zapotosky. "The precise charges the men face were not immediately clear ... Prosecutors have been probing Manafort’s work as a political consultant in Ukraine, where he advised a Russia-friendly political party for years before his work with Trump. They have also been examining Manafort’s personal finances."

--Topline 2018 marketplace data is out. Early this morning, the Department of Health and Human Services released a report detailing premiums and plan options that will be available on Healthcare.gov when it opens on Wednesday for the new enrollment season. The report, prepared by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), includes analysis of qualified health plan data, including insurer participation, plan options and premiums. HHS stressed these figures:

--The average premium for the second-lowest cost silver plan (the "benchmark" plan on which subsidies are based) will increase 37 percent. Last year, this premium increased 24 percent.

--The average annual premium for the benchmark plan for a 27-year old will cost $4,932, up from $2,616 during the ACA's first year. (However, the average premium for the lowest cost silver plan will increase just 17 percent instead of last year's 27 percent average hike.)

--Premium tax credits, which shelter most enrollees from premium hikes, are going up too. The average tax credit will increase by 45 percent, to $555.

--Twenty-nine percent of enrollees will have access to just one health insurance issuer, up from 20 percent in 2017 and 2 percent in 2016.

--Fifty-five percent of enrollees will have the option of two or fewer health insurance issuers offering plans, up from 43 percent in 2016 and 14 percent in 2015.

What's blowing my mind is the contrast between how HHS under Trump is presenting the information, and how the agency presented the information under Obama. In past years, HHS stressed the availability of tax credits for most enrollees. This year, even the subsidy data is being presented as a negative: "Ever-growing subsidies are chasing skyrocketing premiums, pricing out middle-income Americans and turning Obamacare’s exchange into a de facto high-risk pool," the news release from HHS says.

HHS spokeswoman Caitlin Oakley added this: “This data demonstrates just how rapidly Obamacare’s exchanges are deteriorating with skyrocketing premiums year after year, more than half of Americans with no more than two insurers to choose from, and the taxpayer burden exploding. There is an urgent and serious need to repeal this failed law and replace it with patient-centered solutions."

AHH, OOF and OUCH

Maine Gov. Paul LePage (AP Photo/Robert F. Bukaty, File)

AHH: On Nov. 7, Maine voters will be the first in the country to decide by referendum whether the state should accept the Affordable Care Act's Medicaid expansion, the New York Times reports. Republican Gov. Paul LePage (R) has five times vetoed expansion, making Maine one of 19 states whose GOP governors or legislatures have refused to extend the health insurance program for adults earning up to 138 percent federal poverty.

"The other holdouts — particularly Utah and Idaho, where newly formed committees are working to get a Medicaid expansion question on next year’s ballot — are closely watching the initiative, whose outcome may offer clues about the salience of the issue in next year’s midterm congressional elections," Abby Goodnough reports. "Turnout may be the biggest challenge for the advocacy groups leading the effort. There are no national or statewide races here to drive people to the polls this year."

LePage's stance on the program -- he calls Medicaid expansion "pure welfare" that would cost too much, appeals to many rural voters, Abby writes. And Sen. Susan Collins, one of the moderate Republicans who helped sink the Senate's ACA repeal bill, hasn't taken a position on it. If the ballot measure passes, about 80,000 additional Mainers would become eligible for the program.

President Trump, with First lady Melania Trump by his side, speaks before signing a presidential memorandum to declare the opioid crisis a national public health emergency. (Jabin Botsford/The Washington Post)

OOF: Trump vowed a "massive advertising campaign" as part of his emergency declaration to fight opioid abuse, but there's little evidence that similar past marketing efforts have been effective, the AP reports. As he announced a series of response efforts, the president put special emphasis on advertising to discourage kids from trying drugs, saying, “They will see the devastation and the ruination it causes.”

“I think that’s going to end up being our most important thing,” Trump said in his speech last Thursday. “Really tough, really big, really great advertising, so we get to people before they start.”

From the AP: "Yet government and academic assessments of 'Just Say No'-style messages have repeatedly shown poor results. Between 1998 and 2004 the U.S. government spent nearly $1 billion on a national campaign designed to discourage use of illegal drugs among young people, particularly marijuana. A 2008 follow-up study funded by the National Institutes of Health found the campaign 'had no favorable effects on youths’ behavior' and may have actually prompted some to experiment with drugs, an unintended 'boomerang' effect.

"More recently, anti-drug promotions have shifted their focus, appealing to teenagers’ desire for independence and self-control rather than fears about drug use. A 2011 study of the government’s 'Above the Influence' campaign suggested eighth-graders who had seen the messages were less likely to have tried marijuana than those who had not."

Secretary of State Rex Tillerson (AP Photo/Andrew Harnik, File)

OUCH: The State Department has been quietly withdrawing financial support over the past year-and-a-half for children with special needs whose parents are in the Foreign Service, effectively forcing some parents to serve overseas without their children or ultimately resign, The Post's Jackie Spinner reports. The department no longer funds some services that these kids would be entitled to if they lived in the United States, including therapy, one-on-one school aides, periodic retesting, and summer or extended school years.

And there's more: the State Department’s Medical Office, which provides clearance for all diplomats and their dependents to live overseas, is suddenly — and without a formal change in policy — barring some children from going abroad, even if they had been allowed to do so in the past. "One diplomat had to leave his 13-year-old child this year at a therapeutic U.S. boarding school that costs the family more than $60,000. The child, who has emotional problems that are being treated, had been allowed to travel overseas with his family in the past," Jackie writes.

"In a sign of the growing hostility between parents and State Department managers in Washington, administrators of a Yahoo Group used by diplomat parents to trade resources and advice kicked the medical team off," she continues. "Parents also have formed a State Department alliance for families of children with special needs to ask for clarification about how existing regulations are being interpreted and to push for more flexibility in what is covered by a special-needs education allowance. So far, none of their concerns has been addressed, parents and advocates said."

A State Department spokesman said the department is trying better to manage the programs for special-needs dependents and to “improve accountability.” Last school year, the agency paid benefits to more than 1,050 dependents.

TRUMP TEMPERATURE

President Trump. (Andrew Harrer/Bloomberg)

--SUNDAY TWEETSTORM: The president kicked off his five-tweet rant yesterday morning with health-care, because why not? He insisted Democrats still carry the blame for higher premiums (even though insurers say some of their rate hikes are due to the administration's discontinuation of cost-sharing reductions) and promised a repeal bill after a tax overhaul. The Health 202 is wondering why Republicans would be able to rally around an unpopular health-care bill during an election year when they couldn't do teh same an off-election year.

As usual, the ObamaCare premiums will be up (the Dems own it), but we will Repeal & Replace and have great Healthcare soon after Tax Cuts!

BIGGEST DEAL OF THE YEAR would be a mega-merger between pharmacy giant CVS Health and health insurer Aetna if it goes through, my colleague Carolyn Johnson reports. It would also create a combined company less vulnerable to disruption by Amazon, the online retail giant that has been eyeing the pharmacy business.

"Companies like CVS Health are seen as vulnerable on two fronts: An Amazon move into prescription drug sales could encroach on sales at CVS retail pharmacies, which already face strong competition," Carolyn writes. "It could also threaten the big business of negotiating drug prices with pharmaceutical companies."

CVS Health's bid to buy Aetna could be a defensive maneuver. "Under that deal, CVS would become a health-care company that not only sells drugs and negotiates prices but also leverages its patient data to manage health-care costs," Carolyn writes. "For example, a joint CVS-Aetna company could create health-care plans with low co-pays if people seek care at walk-in MinuteClinics to discourage more expensive visits to physicians' offices. It could use its regular contact with patients to get better insight into whether people with diabetes or high blood pressure were filing their prescriptions on time."

“The best way to build a moat around your business from Amazon is to go away from the businesses Amazon will compete with,” said George Hill, a research analyst at RBC Capital Markets.